Clinical Documentation Improvement

2 days ago


Syracuse, New York, United States Crouse Hospital Full time

Since 1887, Crouse Health has been a leading healthcare provider in Central New York. We've combined a family-friendly culture with a passion to provide the best care, which creates an environment where both patients and team members feel valued. Crouse Health offers a full range of general and specialty care, inpatient and outpatient services, as well as community health education and outreach programs.

Crouse's Health Information Management team is hiring a Clinical Documentation Improvement (CDI) Manager.

Pay Range:$115, $135,614.00 / annual

Schedule(s): Full Time, Monday-Friday, 8:00am-4:30pm.

CDI Manager Responsibilities:

  • Undertakes the accountability of the accuracy, completeness, and timely submission of clinical documentation and supervises improvement efforts by providing direction during daily documentation evaluations.
  • Monitors any correspondence between CDI specialists and clinical staff, whether written or verbal, when documentation inaccuracies arise due to illegibility, missing/conflicting information.
  • Collaborates with the HIM Director to assign the urgency status for each query submission, and guides query assignments accordingly (e.g., whether they should be conducted verbally, concurrently, or retrospectively).
  • Supervises any tracking efforts of queries submitted to clinical staff through oversight and maintenance of Crouse's tracking tool.
  • Gathers information related to clinical documentation from CDI Specialists' assembled process reports and verifies any identified root causes of documentation errors for the HIM Director to report in departmental meetings.
  • Attends departmental meetings with various revenue-generating departments where root causes of documentation errors are communicated (i.e., existing discrepancies in diagnoses), and contributes to resolution steps.
  • Provides direction and support to CDI staff by adhering to an established educational plan to ensure quality performance and productivity standards are established and met.
  • Assists the HIM Director in interviewing, hiring, and training employees, maintaining workflow among team members, evaluating performance, and promoting improvement of substandard performance.
  • Maintains current knowledge of medical documentation associated rules and guidelines, and provides guidance on requirements set forth by the Centers for Medicare and Medicaid Services (CMS), other third-party payers, and the American Hospital Association (AHA).
  • Ensures that services are provided in accordance with state and federal regulations, organizational policy, and accreditation/compliance requirements.
  • Demonstrates knowledge of Crouse Health's safety policies and procedures by maintaining a safe environment.
  • Attends and actively participates in hospital or medical performance improvement councils and committees as requested.
  • Participates, collaborates and actively engages in meetings to achieve goals and mutually beneficial outcomes.
  • Conducts regular staff meetings to disseminate hospital and/or department/division information and allows for discussion of staff concerns needing clarification or resolution.
  • Assumes other duties as assigned by department leadership.

CDI Manager Requirements:

  • Must be licensed as a Registered Nurse (RN) in New York State.
  • Bachelor's degree in business, healthcare administration, or a related field required.
  • At least 2-3 years of management experience required.
  • At least 3-5 years of clinical documentation improvement experience required.
  • At least 2-3 years of coding experience required.
  • Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) preferred.
  • Working knowledge of MS Outlook.
  • Extensive knowledge of all components related to clinical documentation.
  • Understanding of clinical processes (complications, comorbidities, severity of illness, risk of mortality, case mix, secondary diagnoses).
  • Ability to integrate clinical and coding processes to improve Crouse Health's health record integrity, regulatory compliance, and rates of reimbursement.

Benefits Overview:

  • Medical, Dental, Vision, FSA, and 401K.
  • Company paid life insurance.
  • Tuition Assistance and Workforce Development Opportunities.
  • Crouse Health Employee Assistance Program.
  • Employee discounts on any Inpatient or Outpatient service, hospital cafeteria and pharmacy, and certain retailers.
  • YMCA Subsidy program.

Location: Crouse Hospital · Health Information Management - 157

Schedule: Full-Time, Days, 8:00-4:30



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